Provider Demographics
NPI:1003077660
Name:GORHAM, DANTE LEMAR (PT)
Entity Type:Individual
Prefix:
First Name:DANTE
Middle Name:LEMAR
Last Name:GORHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 QUEBEC ST
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2128
Mailing Address - Country:US
Mailing Address - Phone:301-434-3658
Mailing Address - Fax:
Practice Address - Street 1:4000 MITCHELLVILLE RD
Practice Address - Street 2:STE A400
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3104
Practice Address - Country:US
Practice Address - Phone:301-805-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHB605ZMedicare PIN
CAW17215CMedicare PIN